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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 10-14

Factors associated with early complications of surgical management due to penetrating laryngotracheal trauma in Colombia


1 Department of Thoracic Surgery, El Bosque University; Department of Thoracic Surgery, Subred Integrada de Servicios de Salud Centro Oriente E.S.E., Bogotá, Colombia
2 Department of Thoracic Surgery, El Bosque University; Department of Thoracic Surgery, Subred Integrada de Servicios de Salud Centro Oriente E.S.E.; Department of Thoracic Surgery, Clínica Reina Sofía, , Bogotá, Colombia
3 Department of Thoracic Surgery, El Bosque University; Department of Thoracic Surgery, Subred Integrada de Servicios de Salud Centro Oriente E.S.E.,; Department of Thoracic Surgery, National Cancer Institute, Bogotá, D.C, Colombia

Date of Submission07-Jan-2022
Date of Decision08-Jan-2022
Date of Acceptance09-Jan-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Mario-Fernando Lopez
Universidad El Bosque, Av. Cra. 9, No. 131 A - 02, Bogotá, DC
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_4_22

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  Abstract 


Background: This investigation aimed to describe factors associated with early complications of surgical management due to penetrating laryngotracheal trauma in Colombia.
Materials and Methods: A descriptive and retrospective cohort study was carried out; bivariate analysis using Pearson's Chi-square and Fisher's exact test was utilized to find associations with morbidity outcomes.
Results: Between 2005 and 2019, 50 patients with penetrating laryngotracheal injuries underwent surgery; the median age was 29.5 years (interquartile ranges = 24.0–39.7), wherein 92% were male. The trachea was the most affected organ in 74% of patients, and lesions associated with laryngotracheal trauma were reported in 50% of patients. Cervicotomy was the surgical approach in 92% of patients. The 30-day overall morbidity was 24%, and mortality was 6%; dehiscence of the primary repair, or anastomosis, was present in 10% of the patients: 2% partial and 8% complete. Dehiscence was associated with infection (P = 0.002). Early stenosis was described in 10% of the patients; association was found between stenosis and dehiscence (P = 0.001), infection (P = 0.001), and reoperation (P = 0.001). Finally, infection was present in 8% of the patients and was indeed associated to the requirement of postoperative intensive care unit (ICU) hospitalization (P = 0.003).
Conclusions: Limited information is available about factors related to early complications in laryngotracheal trauma. Nonetheless, in this series, a statistically significant association was found between early dehiscence of the primary repair, or anastomosis, and infection. Moreover, early stenosis was associated with dehiscence, infection, and reoperation. Finally, early infection was associated with the requirement of postoperative ICU hospitalization.

Keywords: Head and neck, infection, outcomes, trauma


How to cite this article:
Lopez MF, Martínez SI, Carvajal CA. Factors associated with early complications of surgical management due to penetrating laryngotracheal trauma in Colombia. J Cardiothorac Trauma 2022;7:10-4

How to cite this URL:
Lopez MF, Martínez SI, Carvajal CA. Factors associated with early complications of surgical management due to penetrating laryngotracheal trauma in Colombia. J Cardiothorac Trauma [serial online] 2022 [cited 2023 Jun 3];7:10-4. Available from: https://www.jctt.org/text.asp?2022/7/1/10/366396




  Introduction Top


Laryngotracheal trauma is rare; however, it is part of a life-threatening spectrum of injuries as it can cause acute airway obstruction and lead to death at the scene of the accident or crime. In the United States, it represents one in every 5000–30,000 visits to the emergency department;[1] hence, the overall mortality of patients with lesions of the tracheobronchial tree ranges from 17% to 28%, while the overall reported mortality from cervical trachea trauma is 14%.[2] In Bogota, taking into consideration the series published in 1987 by Brieva et al., the overall mortality of cervical trachea injuries was 4% because of associated injuries caused by gunshot wounds.[3]

Due to limited information in the literature, complications of surgical treatment of patients with laryngotracheal trauma are considered similar to those of tracheal resection and reconstruction; anastomotic dehiscence and stenosis are the main conditions reported in up to 5%–6% of the cases.[4],[5] Moreover, factors associated with the prognosis of the surgical repair of airway injuries are not clearly described in most of the series to date. Early diagnosis and correct treatment performance are some of the recommendations which are clearly unspecific.[5] That said, the objective of this study was to describe the factors associated with early complications of penetrating laryngotracheal trauma in a single institution in Bogotá.


  Materials and Methods Top


A retrospective cohort study was carried out; thence, medical records of patients over 18 years old with penetrating laryngotracheal injury and surgically managed at Hospital Santa Clara in Bogotá from January 1, 2005, to December 31, 2019, were reviewed.

Considering the aforementioned, the data obtained were recorded in an Excel spreadsheet and therefore exported to the SPSS (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp) statistical program for the analysis. Numerical variables were described in medians and interquartile ranges (IQR), whereas categorical variables were described in absolute values and percentages. Associations between categorical variables and morbidity outcomes were sought through a bivariate analysis using Pearson's Chi-square and Fisher's exact test; indeed, statistical significance was confirmed with P < 0.05.

The severity of laryngeal lesions was classified according to the Schaefer-Fuhrman (SF) scale, which divides them into: SF-1 minor endolaryngeal hematoma without detectable fracture; SF-2 edema, hematoma, minimal mucosal disruption without exposure of cartilage, or nondisplaced fractures; SF-3 massive endolaryngeal edema, extensive mucosal lacerations, exposed cartilage, displaced fracture, or vocal cord immobility; SF-4 similar to SF3, but with disruption of the anterior portion of the larynx, unstable fractures, ≥2 lines of fracture, or severe mucosal injury; and SF5 complete laryngotracheal disruption.[6]

Early complications were defined as those that occur within the first 30 days of follow-up.

Having said that, the investigation was carried out in regard to the principles of the Declaration of Helsinki (1964) and subsequent amendments, updated in 2013, and it was approved by the Institutional Ethics Committee.


  Results Top


Study population

Between 2005 and 2019, 50 patients underwent surgery due to penetrating laryngotracheal trauma; the average age of patients included was 29.5 years old (IQR = 24.0–39.7), wherein 92% of patients were male.

Now, the average time of hospitalization after surgery was 4 days (IQR = 3.0–7.25). 44% of the patients required hospitalization in the intensive care unit (ICU) in the postoperative period; the median time of hospitalization in the ICU was 4.5 days (IQR = 2.0–6.2). The main symptoms were dyspnea in 74% of the patients, dysphagia in 28%, and dysphonia in 8%; major clinical signs were subcutaneous emphysema in 80% of the patients, stridor in 14%, and hemoptysis in 14%. The main mechanism of trauma was stab wounds in 86% of the patients, followed by gunshot wounds in 14% [Table 1].
Table 1: Characteristics of patients with penetrating laryngotracheal trauma

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As a matter of fact, the trachea was affected in 74% of the patients and the larynx in 26%; the severity of the laryngeal injury was grade S-F2, S-F3, and S-F4 in 61.5%, 23.1%, and 15.4%, respectively.

Injuries associated with laryngotracheal trauma were reported in 50% of the patients, and in some cases, more than one organ was affected: intrathoracic lesion in 34%, vascular injury in 22%, esophageal injury in 14%, and spinal cord injury in 2% of the patients.

Surgical procedure

The median time from injury to repair was 3.3 h (IQR 2.5–6 h). Antibiotic prophylaxis used was cefazolin in 54% of patients, ampicillin/sulbactam in 30%, and 16% did not receive antibiotic prophylaxis. Surgical approaches to repair laryngotracheal injury were cervicotomy in 92%, thoracotomy in 2%, and median sternotomy in 6%; one patient required cervicotomy and sternotomy for repairing a thoracic trachea injury, and one patient required a resuscitation thoracotomy and a subsequent cervicotomy for repairing a laryngeal injury.

Having the above background in mind, primary tracheal repair was performed in 60% of the patients, resection and tracheal anastomosis in 14%, and primary laryngeal repair in 26%. Furthermore, two patients with Grade IV SF laryngeal injury also required tracheostomy as part of the initial intraoperative management [Figure 1].
Figure 1: (a) 27-year-old patient with laryngeal injury Schaefer-Fuhrman IV (b) Laryngotracheal anastomosis

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All the procedures were performed by thoracic or general surgeons, based on the time of the day the patients were admitted and their hemodynamic stability on admission. The decision of primary repair or resection and anastomosis was based on the extent of the lesion and hemodynamic stability of the patient; in cases with extensive tissue necrosis in association with disruption of more than 50% of the tracheal circumference, resection and anastomosis was preferred.

Early complications

Complications within the first 30 days of follow-up were evidenced in 24% of the patients; 16% of whom required reoperation. Dehiscence of the primary repair, or anastomosis, was revealed in 10% of the patients: 2% partial and 8% complete. Even though dehiscence was associated with infection (P = 0.002). It was not related with esophagus or vascular-associated injury (P = 0.684 and P = 0.211, respectively) [Table 2]. In addition, the presence of associated organ injuries was also not related to the need of resection-anastomosis.
Table 2: Associations with early suture dehiscence

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Early stenosis was described in 10% of the patients. Furthermore, an association was found between stenosis and variables such as: dehiscence (P = 0.001), infection (P = 0.001) and reoperation (P = 0.001). [Table 3].
Table 3: Associations with early stenosis

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Infection was evidenced in 8% of the patients; thus, the association among infection and the requirement of postoperative ICU hospitalization (P = 0.003) was found [Table 4]. Some of the antibiotic regimens used for therapeutic purposes included piperacillin/tazobactam and vancomycin; times of treatment ranged from 7 to 14 days.
Table 4: Associations with early infection

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Mortality

There were three intraoperative deaths; two patients had a tracheal injury, and one patient had a larynx injury. Thence, causes of death were associated with intrathoracic injuries (cardiac, pulmonary, and vascular injuries).


  Discussion Top


Blunt trauma is the most common cause of tracheal injury in the world.[6],[7] Mortality can be around 25% in blunt tracheal trauma and 13.6% in penetrating trauma.[1],[8] Laryngeal trauma mortality rate is reported to be between 1.6% and 11% and it is associated with injuries of other organs.[1],[6],[7]

High clinical suspicion, knowledge of the mechanisms of trauma, and adequate medical and surgical management are significant factors to improve survival rates and reduce perioperative complications.[1],[9]

Therefore, definitive diagnosis and treatment of laryngotracheal injuries have been recommended in the first 24 h as it has been demonstrated to provide a better airway permeability and voice preservation.[10],[11]

Bent et al. reported a major difference between early and late repair outcomes and described that incidence of complications was lower among patients with early repair (1.6%) compared to those repaired after the first 48 h (21.4%).[12]

Notwithstanding the foregoing, in this study, the association between those patients who underwent late repair and early complications was not found; presumably related to the fact that in the series presented hereof, 94% of the patients underwent surgery in the first 24 h.

Now, reports in the literature evaluating the short-term complications of penetrating laryngotracheal injuries are limited; for this reason, complications of traumatic laryngotracheal repair are considered similar to those of nontraumatic tracheal resection and reconstruction. Anastomotic dehiscence and stenosis are the main problems reported in approximately 5%–6% of cases in some series.[6],[12]

Dehiscence in primary tracheal and laryngeal repair, or anastomosis, due to nontraumatic lesions occurs in 4.1%–5.8% of the patients.[13],[14] In the series presented hereof, 10% of the patients evidenced suture dehiscence 30 days after surgery, wherein 2% were partial and 8% complete. Anastomotic dehiscence has been associated with the severity of the injury, anatomical location of the wound, time-lapse until repair, and the presence of secondary lesions.[15] None of these associations were found in this series.

Early stenosis was evidenced in 10% of the patients; furthermore, the association between stenosis and suture dehiscence was found. Ensuring a tension-free reconstruction could prevent stenosis of a tracheal anastomosis and complementary maneuvers such as laryngeal and hilar release, which might be required to avoid anastomotic tension.[16]

Well then, a higher complication rate has been associated to severe lesions such as Grade IV and V in the SF classification, which has been estimated at 31% for voice sequelae and 6.1% for any grade of airway obstruction.[6] In the series presented thereof, an association between the severity of the lesion and any complication was not found; nonetheless, this finding may be explained by the small number of patients with severe injuries. Finally, surgical wound infections in penetrating tracheal trauma are reported in up to 10% of the patients.[3] In this series, the infection rate within 30 days after surgery was 8%, and an association between infection and the requirement of postoperative ICU hospitalization was evidenced.

Having said that, it is important to highlight that the limitations of this study are related to its retrospective design, a small number of patients in a single center, and a short follow-up time. Despite this, this study is one of the first to describe the factors associated with early complications of penetrating laryngotracheal trauma in the literature.


  Conclusions Top


Results are consistent with the fact that sharp weapon injuries were the main cause of penetrating laryngotracheal trauma in Bogota, and these injuries were usually corrected by cervicotomy.

Now, a statistically significant association was found between early dehiscence of the primary repair, or anastomosis, and infection; early stenosis was associated with dehiscence, infection, and reoperation. Finally, early infection was associated with the requirement of postoperative ICU hospitalization.

Ethical clearance

The study was carried out in regard to the principles of the Declaration of Helsinki (1964) and subsequent amendments, updated in 2013, and it was approved by the Institutional Ethics Committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee WT, Eliashar R, Eliachar I. Acute external laryngotracheal trauma: Diagnosis and management. Ear Nose Throat J 2006;85:179-84.  Back to cited text no. 1
    
2.
Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: Potential implications for airway assessment and management. Injury 2007;38:27-33.  Back to cited text no. 2
    
3.
Brieva MJ, Penaloza BF, Russi Campos H, Camacho Duran F, Casallas GA. Trauma penetrante de la traquea. Cirugia (Bogotá) 1987;2:36-40.  Back to cited text no. 3
    
4.
Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction. Incidence, treatment, and prevention. J Thorac Cardiovasc Surg 1986;91:322-8.  Back to cited text no. 4
    
5.
Mussi A, Ambrogi MC, Ribechini A, Lucchi M, Menoni F, Angeletti CA. Acute major airway injuries: Clinical features and management. Eur J Cardiothorac Surg 2001;20:46-51, discussion 51-2.  Back to cited text no. 5
    
6.
Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg 1992;118:598-604.  Back to cited text no. 6
    
7.
Khan AM, Fleming JC, Jeannon JP. Penetrating neck injuries. Br J Hosp Med (Lond) 2018;79:72-8.  Back to cited text no. 7
    
8.
Kiser AC, O'Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: Treatment and outcomes. Ann Thorac Surg 2001;71:2059-65.  Back to cited text no. 8
    
9.
Danic D, Prgomet D, Sekelj A, Jakovina K, Danic A. External laryngotracheal trauma. Eur Arch Otorhinolaryngol 2006;263:228-32.  Back to cited text no. 9
    
10.
Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64:203-14.  Back to cited text no. 10
    
11.
Schneider T, Volz K, Dienemann H, Hoffmann H. Incidence and treatment modalities of tracheobronchial injuries in Germany. Interact Cardiovasc Thorac Surg 2009;8:571-6.  Back to cited text no. 11
    
12.
Bent JP 3rd, Silver JR, Porubsky ES. Acute laryngeal trauma: A review of 77 patients. Otolaryngol Head Neck Surg 1993;109:441-9.  Back to cited text no. 12
    
13.
Kapidzic A, Alagic-Smailbegovic J, Sutalo K, Sarac E, Resic M. Postintubation tracheal stenosis. Med Arh 2004;58:384-5.  Back to cited text no. 13
    
14.
Wright CD, Grillo HC, Wain JC, Wong DR, Donahue DM, Gaissert HA, et al. Anastomotic complications after tracheal resection: Prognostic factors and management. J Thorac Cardiovasc Surg 2004;128:731-9.  Back to cited text no. 14
    
15.
Herrera MA, Tintinago LF, Victoria Morales W, Ordoñez CA, Parra MW, Betancourt-Cajiao M, et al. Damage control of laryngotracheal trauma: The golden day. Colomb Med (Cali) 2020;51:e4124599.  Back to cited text no. 15
    
16.
Lanuti M, Mathisen DJ. Management of complications of tracheal surgery. Chest Surg Clin N Am 2003;13:385-97.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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